Mental health clinics cited

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Dozens of therapists who were unlicensed or improperly supervised routinely treated mentally ill patients at three clinics owned by a major provider of care to low-income people in Massachusetts, state records show.

At an Arbour Health System clinic in Lawrence, state inspectors determined that all 23 therapists were not qualified to see patients on their own, yet were doing so without regular oversight by a licensed professional. Similar staffing violations were discovered at Arbour clinics in Malden and Fall River.

The findings last year, described in documents obtained by the Globe and filed as part of a lawsuit, highlight a two-tier system in which low-income patients often are treated by mental health workers with less training and expertise than caregivers for privately insured patients.

The suit, being considered by a federal judge this week, centers on the care that teenager Yarushka Rivera received at the Lawrence clinic. Unlicensed Arbour therapists counseled Rivera and diagnosed her with biploar disorder, according to state records filed in the case, brought by the girl’s parents. They allege that a nurse working without adequate supervision prescribed an antiseizure medication often given for mood disorders though not federally approved for such a use.

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Rivera, called Yari by her friends, developed a seizure disorder after she stopped taking the drug. In October 2009, soon after graduating from Essex Agricultural and Technical High School, she suffered a seizure and died at age 19. The family’s suit does not blame Arbour for Rivera’s death but instead seeks redress by claiming the company fraudulently billed government insurance programs.

The state Department of Public Health, which regulates community mental health centers, required Arbour last year to develop plans to fix the problems at the cited clinics. Among other steps, the company promised to hold regular supervisory meetings with therapists and improve monitoring by clinic directors.

Dr. Madeleine Biondolillo, director of the department’s Bureau of Health Care Safety and Quality, said the pattern of deficiencies is concerning, but she is satisfied with Arbour’s promise to do better.

“This is an organization that has broad reach,” she said. “It’s a very, very important service that they provide, and it has to be done according to the regulations.”

Arbour operates five psychiatric hospitals and 11 mental health clinics in Massachusetts. Its for-profit parent, Universal Health Services, is a publicly traded company that earned more than $443 million last year and has staked its future largely on expanding in the behavioral health care market.

State regulations allow unlicensed workers to see patients in community mental health clinics, which serve large numbers of people who are low income or have serious mental illness — but only if those workers are regularly supervised by licensed mental health professionals. The practice is meant to ensure access to affordable mental health providers and to provide experience to therapists applying for licensure. Unlicensed workers can also fill a need for caregivers who speak Spanish or another language.

But the supervisory lapses at Arbour show that the state policy, if not aggressively enforced, can contribute to a care gap: People with top-shelf commercial insurance plans or who can afford to pay cash get access to fully licensed social workers, psychologists, or psychiatrists, while those who are low income may see clinicians with far less training.

Rivera’s mother and stepfather, Carmen Correa and Julio Escobar, noted in one of the numerous complaints they filed with the state that it makes little sense for Massachusetts to allow unlicensed workers to treat sick patients when even manicurists must be licensed. State rules “fail to protect our most precious treasure and most vulnerable, which are our mentally disabled children,” they wrote.

Rivera’s parents filed their lawsuit against Universal Health Services in federal court in Boston in 2011, alleging that the company defrauded the state and federal government by charging for services provided by therapists unqualified to care for their daughter, who was covered by Medicaid.

They declined to comment for this story. If they win their case, the couple would receive a portion of what the government recoups in payments made to Arbour.

Universal has argued that the case does not belong in court because the issues raised are a matter of compliance with state regulations, not of federal fraud. US District Judge Douglas P. Woodlock heard arguments Wednesday afternoon on the company’s motion to dismiss the suit but made no immediate ruling.

Mark Pearlstein, Universal’s attorney, said in an e-mail that the family’s complaints have not resulted in fines or revocation of the clinics’ licenses. Some Lawrence employees have been disciplined by state licensing boards, however.

Arbour “is defending this case vigorously and expects to be vindicated when the matter is ultimately concluded,” Pearlstein said. The company’s lawyers declined to comment on the state inspectors’ findings.

Nearly every Arbour caregiver who treated Rivera in the two years before she died lacked proper qualifications or professional supervision, according to court records.

In 2007 and 2008, Rivera saw two counselors, neither of whom had any professional license. When her parents complained in early 2009, clinic director Edward Keohan suggested that she see Anna Fuchu, who described herself as a psychologist. After a brief evaluation, according to the court filing, Fuchu diagnosed Rivera as bipolar.

Fuchu was not licensed as a psychologist in Massachusetts, despite representing herself as one on Facebook and elsewhere online. Last year she agreed to pay a penalty of $1,000 and promised the state Board of Registration of Psychologists not to use the title.

In May 2009, Rivera’s school said she would need an evaluation by a psychiatrist. Fuchu suggested Rivera see Maribel Ortiz, a licensed nurse practitioner at the clinic, the court documents said.

Ortiz prescribed the antiseizure medication. She had the authority to write prescriptions as long as she had proper supervision from a psychiatrist. Ortiz’s supervisor was a physician but not a board-certified psychiatrist, and she did not have the qualifications to supervise Ortiz, according to state records included in the court filings. The company later told the state that the supervisor was eligible for board certification and planned to take the required exam last fall.

When regulators visited the Lawrence facility in March and April
of last year after receiving complaints from Rivera’s family, they found that all clinical therapists were working without the necessary licenses or oversight.

Keohan, the clinic director and a licensed independent clinical social worker, told inspectors that he had been “unaware that supervision was required to be provided on a regular and ongoing basis,” the report said.

Keohan separately acknowledged to the state board that licenses and disciplines social workers that he allowed someone he supervised to act as a social worker though that person was not licensed, and agreed to a two-year probation. He also failed to complete continuing education courses and kept poor patient records, the board found.

Keohan, Ortiz, and Fuchu did not return calls requesting comment for this story.

While investigating the Lawrence clinic, inspectors found that five more Arbour therapists who were not licensed to practice independently went without regular supervision at a clinic in Malden. The company later said that a supervisor had been working with several of those therapists but didn’t chronicle their meetings. The clinic had been cited previously, in 2008, for not keeping records of supervision.

State inspectors also visited Arbour’s Fall River clinic last spring and found that 13 of 27 therapists had refused supervision by the clinic director but were permitted to continue treating patients.

Community mental health clinics serve vulnerable people, including children and adults who may be suicidal. Patient advocates and policy leaders say that intensive management is essential to providing good care in a fast-changing field.

“We have set up a structure that assures oversight so that people, when they are seen by someone who is less experienced and not yet holding that license, that there’s a checks and balance system,” said Barbara Leadholm, former commissioner of the state Department of Mental Health. “I think all of us feel we can sleep well with that system.”

That accountability repeatedly was found to be missing at Arbour clinics. Some industry representatives say that points to a need for better enforcement, not a change in the rules.

Some hospitals have shuttered psychiatric units in recent years, and clinics have closed their doors, too, facing low payments from Medicaid and commercial insurers and high psychiatry costs, said Vic DiGravio, president of the Association for Behavioral Healthcare. Unlicensed employees are more affordable.

“Our members really do depend on a workforce that is, in part, not licensed,” said DiGravio, whose group represents mental health clinics in the state, though not Arbour’s. Those employees are “creating access [to care] that otherwise would not be there at all.”

Universal Health Services is a significant part of the Massachusetts mental health system. Arbour operates nearly one of every five inpatient psychiatric beds licensed in the state.

Arbour executives were previously accused by the federal government of improper billing. In 2004, three affiliated companies agreed to pay the federal government $297,545 to settle claims that they had billed Medicare for services provided by doctors when patients actually had been treated by lesser-paid nurses.

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